Surgical Pathology Of The Esophagus PDF

SURGICAL PATHOLOGY OF THE ESOPHAGUS Prof. Dr. Dorel Firescu Elements of esophageal anatomy is a muscle-membrane conduit connects the pharynx to the stomach the upper limit - the junction with the pharynx corresponds to : ▪ the lower edge of the cricoid cartilage ▪ the sixth cer...

SURGICAL PATHOLOGY OF THE ESOPHAGUS Prof. Dr. Dorel Firescu Elements of esophageal anatomy is a muscle-membrane conduit connects the pharynx to the stomach the upper limit - the junction with the pharynx corresponds to : ▪ the lower edge of the cricoid cartilage ▪ the sixth cervical vertebra -C6  lower limit - in the abdominal cavity ▪ at the junction with the stomach ▪ corresponds to the sphincter called cardia  the segments of the esophagus by the regions of the body it passes through: ▪ cervical ▪ thoracic = mediastinal ▪ diaphragmatic ▪ abdominal  the average length of the esophagus is 25 cm distributed as follows: ▪ 5 cm cervical portion; ▪ 16 cm thoracic portion; ▪ 1.5 cm diaphragmatic portion; ▪ 2.5 cm abdominal; from the dental arch to the upper opening of the esophagus -14 -15 cm; ▪ dental arch -> dental arch = 15 cm + 25 cm = 40 cm;  presents 3 straits: ▪ cricoid; ▪ bronchoaortic; ▪ diaphragmatic; Straits are the place of choice for stopping accidentally swallowed foreign bodies;  relations with: ▪ trachea; ▪ left recurrent nerve; ▪ recurrent lymph nodes; ▪ branches of the thyroid arteries; ♦ its vertical fixation is achieved by: muscle extensions to nearby organs: ▪ trachea; ▪ bronchitis; ▪ pleura; ▪ pericardium; own vessels and nerves; is compared to a hanging plant; ♦ Structure: adventice - on the outside: ▪ denser in the diaphragmatic part; ▪ helps keep the esophagus in the oblique position it has when crossing the diaphragm muscle; muscle tunic made up of: ▪Longitudinal fibers on the outside; ▪Inner circular fibers;  submucous tunic; mucous tunic; vessels that irrigate the esophagus: ▪ borrowed from neighboring bodies; nerves come from: ▪ vagus nerve; ▪ glossopharyngeal; ▪ cervical sympathetic; ▪ form two plexuses: - muscular; - submucos; ♦ esophageal hiatus: bordered by the two pillars: ▪ right and left; ▪ tie this hole closed; ▪ participates in achieving a separation of esogastric flows; ♦ opening in the stomach = an opening called cardia; sphincter role more functional than anatomical; here is the Gubarow valve; Vascularization and relationships of Exploration of the esophagus ♦ Radiologic exploration of the esophagus may be : without contrast = plain thoracomediastinal radiograph when, ▪ may appear: - mediastinal widening - in large esophageal dilatations; - mediomediastinal hydroaeric level  with contrast substance: ▪ with simple contrast: - more common in patients with retained foreign bodies; ▪ double contrast: - must be carried out : ▫ in orthostasis; ▫ supine; ▫ in ventral decubitus; - is the exploration of choice in esophageal pathology; - the vast majority of lesions are detected; ♦ Conventional and/or endoscopic ultrasound are used for screening: ▪ gastroesophageal reflux; ▪ effectiveness of anti-reflux surgical procedures; ▪ tumors above the esogastric junction; ♦ Upper digestive endoscopy is a < invasive method than radiologic examination; provides imaging information about esophageal lesions; has purpose: ▫ explorer; ▫ therapeutic;  allows: ▫ sampling for HP; ▫ foreign body extraction; ▫ polypectomy; ▫ banding of esophageal varices; ♦ Esophageal manometry consists of measuring intraesophagea pressure is useful in: ▫ hot flashes; ▫ reflux esophagitis, e.t.c.; ♦ pH-metry measures esophageal pH; can be performed either: ▫ in a single determination; ▫ in a 24-hour monitoring; SURGICAL PATHOLOGY OF THE ESOPHAGUS Prof. Dr. Dorel Firescu  Acute post-caustic esophagitis conditions caused by ingestion of caustic substances; ingestion can be: ▪ voluntary; ▪ accidental; substances can be: ▪ acids; ▪ bases;  example: ▪ caustic soda; ▪ sulfuric acid; ▪ nitric acid; ▪ hydrochloric acid, e.t.c.; ♦ Pathophysiology Acute corrosive esophagitis has a chronic course; the course is completed by a scarring esophageal stenosis; the site and intensity of esophageal lesions depend on: corrosive substance ► nature: ▪ bases cause lesions: - more limited in extent; - deeper into the esophageal wall; ▪ acids cause lesions: - stretched; - superficial; ►quantity; ► concentration; duration of contact with the esophagus - direct proportionality; the precocity of first aid; the quality of first aid;  lesions of: oral cavity; pharynx; larynx; stomach; ♦ Pathologic anatomy four phases are described: 1. hyperemia and edema phase occurs immediately after ingestion of caustic; mucous may be: ▫ edema; ▫ with areas alternating between lividity and ecchymosis; ▫ areas of sloughing that can be removed by shedding; 2. ulceration phase : occurs after detachment of fibrin membranes; ulcerations of variable depth: ▫ superficial ulcerations; ▫ up to perforation ± involvement of periesophageal tissues;  is the phase: ▫ local suppuration; ▫ the infectious picture; ▫a change in general condition; 3. repair phase onset about 2 weeks after the accident; is the appearance of : ▫ granulations; ▫ buds on ulcerated areas of lesions; 4. healing phase = chronic esophagitis phase occurs in 4-6 weeks after the accident; consists in making scars: ▫ retractile; ▫ more or less stenosing; ♦ Clinic we distinguish three phases: acute phase: symptomatology ≠depending on the severity of lesions; shock dominatesin severe injuries; even with intensive treatment can end in death; dominant symptoms consist of: ▫ dysphagia; ▫ retrosternal pain;, ▫ regurgitation;  the course may be complicated by: ▫ bronchopneumonia; ▫ pulmonary abscess; ▫ subphrenic abscess; ▫ esophageal perforation with mediastinitis; the acute phase lasts about 14-15 days after the accident; overlying edematous and ulcerative lesions;  subacute phase = intermediate period lasts: ▫ in medium forms - 2-3 weeks; ▫ in severe forms 2-4 months; nutrition returns to normal; the sick person thinks he is cured = it is the deceptive period; esophagoscopic - bleeding areas of granulated mucosa;  chronic phase, inevitable, is the stage of scar stenosis, begins at the end of the first post- accident month, ends 50-120 days after the accident. ♦ Evolution and complications the evolution is progressive; burdened by complications that can be: spontaneous; the result of dilator treatments; of esophageal stenosis; complications can be:  early - the most common are: ▫ Laryngeal edema; ▫ esogastric hemorrhages; ▫ septic complications caused by: ▪ postcaustic perforation: - esophageal; - gastric with secondary peritonitis; ▪ e.t.c. aspiration pneumonia;  late: ► scar stenosis: ▫ pharyngolaryngeal; ▫ esophageal; ▫ mediogastric; ▫ pyloric;  ► esophageal diverticula; ► Esobronchial fistula; ► corrosive carcinoma of the esophagus; ► gastric cancer grafted on a corrosive gastritis; ♦ Treatment Emergency treatment includes: ► Shock combat that aims to: - fight pain using: ▫ Pain relievers; ▫ sedatives; - combat collapse using infusions with: ▫ physiologic ser; ▫ macromolecule; ▫ blood transfusions; ▫ plasma; ►neutralization of toxic : ingestion of diluents or neutralizing liquids chemically opposite to caustic: acid burns (sulfuric, nitric, hydrochloric): ▫ calcium magnesia (15-20g per 1/2 liter of water); ▫ lime water (100g); ▫ Albumen water (4 egg whites to 1/3 liter of water); ▫ sodium bicarbonate solution;  alkaline burns (caustic soda): ▫ lemon juice; ▫ vinegar (100g/liter of water); ► treatment of esophageal heartburn is by ingestion of: ▫subnitrate of bismuth; ▫caolin; small infusions of plasma to combat leakage; ► Disinfection of the esophageal wound is achieved by: resting the esophagus: ▫ any oral feeding is forbidden; parenteral antibiotic treatment; ► rehydration and parenteral nutrition is done by infusions with: ▫ isotonic solutions; ▫ plasma; ▫ albumin, e.t.c.; ►gastrostomy and feeding jejunostomy: – indicated for severe dysphagia; ► corticosteroid anti-inflammatory treatment; ► antibiotic treatment; Dilator treatment is to direct the healing process; aims to obtain an esophageal lumen as close to normal as possible; is made with different types of spark plugs;  can be set up: ▪ early: ▫ from the 2nd day after the accident, ▫ with the risk of perforative complications, ▫ but with the advantage: - shorter treatment; - more stable results; ▪ late ▫ 3-4 weeks - even 2-3 months after the accident; can be: ▪ anterograde or ▪ retrograde (through gastrostomy); dilator treatment is usually done in ENT services; Surgical treatment can be: 1. emergency : addresses acute life-threatening complications; consists of: ▪ emergency laparotomy with gastrectomy - in post-caustic gastric necrosis; ▪ thoracotomy with esophagectomy in the case of a compromised esophagus and imminent risk of perforation and consequent mediastinitis; 2. early addresses the inability to resume feeding; consists of: ♦ feeding stoma in esophageal stricture: ▪ gastrostomy; ▪ duodenostomy; ▪ jejunostomy; ♦ gastric resection in gastric stenosis; 3. late addresses established esophageal strictures; consists of esophagoplasty = construction of a neoesophagus; various reconstruction methods and materials are used: ▫ abdominal wall skin; ▫ the entire stomach; ▫ large gastric curvature; ▫ small intestine; ▫ cecoascedent; ▫ transverse colon, e.t.c.  they can be passed: ▪ presternal subtegum; ▪ transhiatal mediastinal; Post-caustic esophageal strictures it is one of the late complications of postcaustic esophagitis; consists in reducing the size of the esophageal lumen; are the result of vicious scars installed late;  the location is preferably within natural straits: ▫cricoid; ▫aortic; ▫bronchică; ▫diaphragmatic; their number is multiple; unlike other causes of stenosis that have a unique localization; Pathology ♦ esophageal stricture starts to form in week 4; by degeneration of muscle and nerve fibers into inflammatory modified fibrous bands;  the scar formed is rigid; it doesn't regain flexibility until 6 months after the accident; stiffness may be maintained for more than a year by esophageal dilatations which are irritative factors; ♦ upstream of the stricture: a pouch is formed by dilation of the esophagus, where: food accumulates -by fermentation => causes: ▫ esophagitis lesions; ▫ favor the development of esophageal diverticula;  downstream of the narrowing, a wall flattening process. stenosis may look like: ▫ valve; ▫ circular; ▫ tubular; Symptomatology ► dysphagia installed relatively quickly; is progressive; ▪ in the beginning for solids; ▪ then for semisolids and solids; ▪ finally for liquids; ►regurgitations: in recent stenosis -> immediate postprandial regurgitation - the esophagus has not had time to dilate compensatorily; in the old stenoses with constituted suprastrictural pouch regurgitation has: ▫ old food content; ▫ fetid odor; ► hypersalivation and saliva regurgitation are due to: suprastrictural saliva accumulation; salivary gland hypertrophy; ►general signs are represented by: marked thirst; starvation; gradual alteration of general condition; emaciation of the sick;  complications: ► nutrition; ► dehydration; ► hypoproteinemia; ► anemia; ► local rhino-pharyngo-tracheo- tracheo-bronchial infections; ► general infections caused by decreased resistance (tuberculosis, furunculosis, e.t.c.); ► "untreated" mortality is between 12 and 22%; Treatment dilatation of stenoses in the phase of chronic esophagitis; stenosing scar formation; aims to direct the healing process;  surgical treatment in the phase of organized stenosis and can track: ► only patient feeding: ▫ feeding gastrostomy; ▫ jejunostomy-when the stomach is affected; ▫ Anthropic resection - when sclerosing lesions are confined to this level; ► ► restoration of orogastric transit;  consists in making a neoesophagus; the operation is called esophagoplasty; this neoesophagus can be made of: - tegument ♦ very little used today; ♦ two procedures are described: ▫ Ion Jianu: ▪ the best known; ▪ uses the abdominal integument; ▪ passed through a presternal subtegumental tunnel; ▫ Bircker; - gastric material, namely ► Kirschner procedure: ▫ uses the stomach in its entirety; ▫ past subtegumentar; ► the Amza Jianu procedure which: ▫ utilizes the great gastric curvature; ▫ mounted antiperistaltically; ▫ subtegumentar; ► Lortat-Jacob procedure which: ▫ utilizes the great gastric curvature; ▫ passed under the integument; ▫ isoperistally mounted; ► Dan Gavriliu procedure: ▫ the most commonly used gastric tube procedure in the great curvature; ▫ for high mobilization of the stomach practice splenectomy in hil; - jejunal cramp ► Roux process; ► Lexer process; ► Herzen, e.t.c.; - esophagoplasty with colon, being known: ► the Orsoni process which: use the surgical left colon; to the first sigmoid artery; uses the right colic artery as a feeding vessel; this tube is passed underneath the tube; ► Wulliet-Kelling process: use the transverse colon; vascularized by the middle colic artery; the montage is passed subtegumentar presternal; ► Roith process: use the right colon;  Peptic esophagitis is a chronic inflammation of the lining of the terminal esophagus in the immediate vicinity of the cardia; is caused by contact with refluxed acidic gastric juice;  most commonly, as a result of cardiac incontinence; rarely it can be secreted right down the terminal esophagus; source - heterotopic gastric cell plate; Etiology ► spontaneous abnormalities or deterioration of the heart in: hiatal hernia; scleroderma of the esophagus; brahiesophagul; obesity; chronic bronchitis; chronic vomiting (e.g. from pregnancy), e.t.c.; ► Accidental or iatrogenic trauma of the esophagogastric junction: exogastric anastomoses; esogastric resections; Cardiac interventions - Heller cardiomyotomies; subdiaphragmatic vagotomy; ► particular precautions: gastroduodenal ulcer; biliary disorders; chronic alcoholism; t.b.c-ul; nasogastric tube maintained for a long time; Pathology macroscopic ► Several types of esophageal lesions have been described endoscopically: congestive; hyperplastic; pseudomembranous; ulcerohemorrhagic; ► lesions are confined up to 5-6 cm cranial to the cardia; ► may be accompanied by bleeding: hidden - when the lesions are superficial, do not go beyond the muscle; large bleeding -when the lesions are deeper; ► can cause peptic ulcer - rare; It has been described : ► reactional periesophageal sclerosis; ► esophagitis: catarrhal, pseudomebranous ► ulcerative forms can lead to complications such as: stenosis; periesophageal sclerosis; even malignization;  microscopic ► ulcerative processes with infiltrate are found: lymphocyte; lymphoplastic; histiocyte; Clinic ► clinical picture = esophageal syndrome; ► have a long evolution of about 5-10 years; ► goes through two phases: of peptic esophagitis; stenosis; ► clinical signs in the phase of peptic esophagitis: dysphagia which: ▫ dates back several years; ▫ can be: - intermittent; - progressive;  retrosternal pain ▫ triggered by passing food; ▫ has an anginal type character; pirozisul ▫ occurs in dorsal decubitus; ▫ is nocturnal; ▫ is accompanied by regurgitation favored by increased intra-abdominal pressure;  bleeding ▫ are generally occult; ▫ can cause secondary iron deficiency anemia; regurgitation and belching ▫ usually appear in the morning; ▫ are accentuated by concurrent sialorrhea; ► in the phase of stenosing peptic esophagitis clinical signs : sometimes occur relatively quickly; severe dysphagia that quickly becomes full; is followed by significant weight loss; Paraclinical diagnosis ► Radiologic examination may reveal: thickened folds typical of esophagitis; even ulcer in the terminal esophagus; esophageal stenosis; gastroesophageal reflux: ▫ either in the Trendelenburg position; ▫ either by increasing abdominal pressure;  esophageal stricture in the stenotic form is not accompanied by: ▫ picture incomplete; ▫ rigidity; ► Endoscopy is the paraclinical examination of choice; establishes the diagnosis; may take a fragment for histopathologic examination; ► Esophageal manometry not indispensable; ► Determination of pH in the lower esophagus: a probe called Zeromatic is used; it causes the patient gastroesophageal reflux by: ▫ Lean forward position; ▫ Valsalva maneuver; Evolution ► in mild forms without treatment may have: long evolution; of the order of years; without major complications; the most common complications are: ▫ bleeding; ▫ stenoses; Treatment ► Conservative treatment: diet and hygiene; antihistamines; antispasmodics;  treatment of conditions that can cause esophageal reflux: ▫ obesity; ▫ chronic bronchitis; ▫ gastroduodenal ulcer; ▫ Biliary lithiasis; dilator treatment with spark plugs; ► Surgical treatment aims: fighting acid reflux; recalibration of the esophageal hiatus; decrease of the chlorhydropeptic factor;  as surgical methods are used: Hiss angle restoration; Nissen fundoplication; vagotomy and pyloroplasty; in stenosing forms: ▫ upper polar esogastric esogastric resection; ▫ esophagoplasty;  PA 27-10  Esophageal diverticula sacciform dilatations starting from the circumference of the esophagus outward; communicates with its lumen through an orifice; looks like a glove finger; more common in segments: ▫ pharyngoesophageal; ▫ Thoracic esophagus; Etiopathogenesis rare condition; more common in men than women; most often developed on a dystonic terrain; by the time of appearance we distinguish diverticuli: ▫ congenital; ▫ acquire;  by esophageal topography we distinguish diverticuli: ▫ cervical; ▫ upper thoracic; ▫ mediothoracic; ▫ epiphrenic; ▫ cardioesophageal;  two types of diverticuli are described according to their mode of formation: pulse: are made up of the esophageal mucosa and submucosa; herniates through a hole in the esophageal muscle; the orifice can be: ▫ preformatted; ▫ neoformat;  occur due to increased intraesophageal pressure; describe: ▫ Zenker's pharyngoesophageal diverticulum; ▫ supradiaphragmatic diverticulum = epiphrenic; - occur more in men; - on the right side of the esophagus;  traction: caused by inflammatory phenomena of periesophagitis; works by pulling on the esophagus; more often in its middle portion; realizes so-called parabronchial diverticuli; Clinic ► diverticula are generally asymptomatic for a long time; ► become symptomatic by one of their complications: diverticulitis; compression phenomena; ► clinical signs may be initially discrete: pharyngoesophageal paresthesias; sialoree; followed by the onset of dysphagia: ▫ high and initially capricious for Zenker diverticula; ▫ or low for the epiphrenic; ► eventually dysphagia may become total => sickness; ► other symptoms: for epiphrenic diverticula: ▫ retrosternal pain; ▫ regurgitation; for Zenker diverticula: ▫ left laterocervical pseudobullous pseudofluctuent swelling; ▫ garguimente; ▫ asphyxiation phenomena; ► the diagnosis is established on: anamnesis; physical examination; radiologic examination; or/and endoscopic examination; Evolution without treatment is complicated by: diverticulitis; perforation; malignant degeneration; Treatment ► for Pulmonary diverticula is usually surgical and consists of excision of the diverticulum: ▫ cervical for Zenker; ▫ by thoracotomy for those with epiphrenia; traction diverticula are mainly treated with medication;  Cardiospasm ► is also called: Cardiac achalasia; idiopathic megaesophagus; esophageal dystonia; ► characteristic lesion is: sometimes enormous dilatation of the cranial 2/3 of the esophagus while the distal end is thin; Etiopathogenesis and epidemiology ► etiology unknown; ► seems to include factors: infectious; autoimmune; family; environmental; ► the condition occurs in both sexes in equal percentages; ►can occur at any time in the patient's life; ► a maximum risk between 30 and 55- 60 years of age; ► there have been many theories:  Miculitz's theory = permanent spasm of the cardia ▫ gave the name cardiospasm; ▫ invalidated by the anatomical absence of a proper sphincter;  Hurst's theory of achalasia ▫ Lack of coordination- esophageal peristalsis/opening of the cardia; ▫ The cardia opens passively under the weight of the fluid column; ▫ disorder attributed to damage to the nervous system; ▫ A special role is played by the Auerbach plexus; ▫ experimentally demonstrated by: ▪ reproduction of the disease in cats following injury to this plexus after phenol injection into the esophageal wall; ▪ lesions found in the same plexus in Chagas disease most commonly found in Brazil; Pathology Macroscopic ► in the early stage and state period: fusiform dilatation of the supradiaphragmatic esophagus; cardia remaining in the esophageal axis and narrowed; without inflammatory phenomena of stenosis; ► advanced stage: dolichoesophagus = dilation + elongation; rests on the diaphragm like a "sock"; Microscopic ► initially: hypertrophy of muscle fibers; an important mucosal inflammatory process; ► in advanced stages: mucosal ulcerations; Clinic ► the debit can be: insidious; suddenly after: an emotional shock; ingestion of a particular food; ► typical clinical signs: dysphagia which is: intermittent; with irregular intervals of silence; paradoxical = liquids and not for solids; can become total; can be accompanied by: ▫ palpitations; ▫ retrosternal embarrassment;  regurgitation occur much later than dysphagia; have food content; in the late stages of the disease have a fetid odor, due to stasis; retrosternal pain pirozisul resistant to antacid treatment; Evolution ► is long-lasting; ► capricious; ► can be complicated with: esophagitis - manifested by: ▫ occult bleeding; ▫ painful dysphagia; lung infections - esophageal stasis aspiration; malignization; cachexia; perforation; ► paraclinical diagnosis: plain chest X-ray may reveal a widened mediastinum; esophageal transit barite highlights: ♦ in the early stages: Uniformly dilated supradiaphragmatic esophagus; lower segment of normal size or smaller; ♦ in advanced stages: plenty of stasis fluid; image of "snowflakes" or "sock" ; endoscopic examination allows differentiation from a cancer; Treatment ► has irreversible evolution. ► hygienic - dietetic and medicinal treatment with inconsistent results: nitrates; calcium channel blockers; ► dilator treatment uses: ♦ pneumatic probes inserted with guide wire; ♦ endoscope; ♦ spark plugs; good results: ♦ in 80% of cases; ♦ for variable time intervals;  does not actually solve the underlying condition; reduce cardiac stenosis; dilations should be done progressively as they can cause: ♦ hemorrhage; ♦ perforation - with or without mediastinitis; ► surgical treatment; first imagined by Heller in 1913; consists of extramucous esocardiomyotomy; today we associate an anti-reflux mechanism; the most commonly used antireflux method is hemifundoplication;  currently in use: ♦ laparoscopic minimally invasive methods of myotomy; ♦ accompanied by endoscopic transillumination;  Esophageal cancer is a fortunately rare neoplasia; the diagnosis is most often late; has an unfavorable prognosis; Epidemiology incidence increases with age; occurs in the 6th-7th decade of life; the main risk factors are: ♦ alcohol; ♦ smoking; ♦ food too hot, too cold, ♦ food that has not been ground  other incriminated risk factors are: ♦ achalazia; ♦ Plummer Wilson syndrome; ♦ Barett's esophagus (metaplaced columnar epithelium); ♦ chronic esophagitis ♦ reflux esophagitis ♦ local irritants (at the level of natural straits) Histopathology 80% are squamous cell carcinomas: ♦ more commonly located in the first 2/3 of the esophagus; esophageal adenocarcinomas: ♦ is most commonly located in the lower 1/3 of the esophagus; ♦ occur on pavement metaplasia lesions of the distal esophagus: ▫ Barett's esophagus;  other histopathologic types: ♦ sarcoame; ♦ lymphoma; ♦ adenoid cystic carcinoma; Clinical diagnosis ► unfortunately in the vast majority of cases, the diagnosis is made late; ► symptoms: dysphagia; odynophagia; weight loss - a sign of unfavorable prognosis; ► advanced lesions cause signs of invasion of neighboring structures: hemoptysis-secondary to esophago-tracheal fistula; persistent cough; melena ; invasion of the superior vena cava; Paraclinical diagnosis Esophageal barite transit allows to highlight the tumor formation; Esophagoscopy can directly visualize lesions; allows biopsy; Exfoliative cytology ♦abrasive brushing on: ▪ esophageal tube; ▪ esophageal endoscopy  Computed tomography provides additional information: local extension; regional extension; distant metastases: ♦ pulmonary; ♦ hepatic, e.t.c.;  Transesophageal ultrasound complete the CT exam; allows better assessment of parietal invasion; Bronchoscopy when the tumor is located in the middle 1/3 of the esophagus; to specify the tracheal invasion;  Laboratory tests; Chest X-ray; Liver ultrasound; Bone scan - if symptoms are present; TNM - UICC staging ( 1998 ) Clinical classification T - primary tumor To - no signs of primary esophageal tumor Tis - carcinoma in situ T1 - invading tumor:  lamina propria;  submucous; T2 - tumor invading its own muscle; T3 - tumor invading the adventitia; T4 - tumor invading adjacent structures; N - regional ganglia; N0 - no metastases in regional lymph nodes; N1 - metastases in regional lymph nodes; M - presence of distant metastases; M0 - without the presence of distant metastases; M1 - with the presence of distant metastases;  For upper esophageal tumors M1a - metastases in cervical lymph nodes M1b - other distant metastases  For tumors of the middle thoracic esophagus M1a - not applicable M1b - other distant metastases or metastases in non-regional lymph nodes For tumors of the lower esophagus: M1a - metastases in celiac lymph nodes M1b - other distant metastases Grouping by stages: Stage 0 Tis Tis N0 M0 Stage I T1 T1 N0 M0 Stage IIA T2-3 N0 N0 M0 Stage IIB T1-2 N1 M0 Stage III T3 N1 M0 T4 any N M0 Stage IV any T any N M1 Stage IVA any T any N M1a Stage IVB any T any N M1b Differential diagnosis ► is made with: esophageal benign esophageal tumors; benign esophageal stenosis; postcaustic esophageal stenosis; achalazia; Progress and complications ► Cancer spreads: lymphatically - in regional lymph nodes; by contiguity- affecting the mediastinal organs: trahee; bronhii; spinal column; pericard; diaphragm;  hematogenously in: lung; liver; adrenal; Treatment ► Surgical treatment indicated in localized disease; esophagectomy may be performed: ♦ transthoracic; ♦ transhiatal; restoration of transit by one of the known methods of esophagoplasty; ► Radiotherapy can be administered: ▪ preoperative; ▪ postoperative; when there are contraindications to surgery: ▪ advanced age; ▪ comorbidities; ▪ low performance index;  esophageal carcinoma has a high radiosensitivity; in advanced stages the aim of treatment is palliation; symptoms such as: ▪ dysphagia; ▪ pain; Chemotherapy can be administered: ▪ preoperatively-improves the resectability rate; ▪ Concurrent - in advanced stages cytostatics used in esophageal cancer are: ▪ cisplatin; ▪ taxol; ▪ 5-florouracil; Prognosis ► 5-year survival is only 12%; ►prognosis of esophageal cancer is very serious; ►prognosis depends on: tumor size; localization;  depth of tumor invasion; regional lymph node status; presence of distant metastases; weight loss;